ethics: caring for people with mental illness Flashcards
how to define mental illness
When we identify lesions, neurochemical imbalances or ontogenic (developmental) deviations in the brain we identify (neuro)physiological problems, albeit ones that can result in behavioral/ experiential symptoms. What is it for a mental state to be ‘ill’, disordered or pathological? Even if we presume the presence of a ‘neurochemical imbalance’, we might still question how to generate criteria that differentiate between depression as a normal part of life (grief, say) and when it becomes something of clinical significance such that (medical) intervention is justified. Equally, how do we differentiate between someone who is anti-social and someone with anti-social personality disorder. Or between those who are shy and those who are appropriately diagnosed as having social anxiety. Similarly, we might wonder if dyslexia can count as a disease, illness or disorder for those that live in preliterate societies. A point that finds broader expression in the notion of neurodiversity.
changes: what we see as mental illness
Historical they way mental illnesses have been understood has varied. Some conditions were previously thought to mean an individual was ‘touched by god’ or that they were communing with the spirit world. More recently, some have been considered criminal matters (certain sexual philias, for example) or as reflecting poor moral character (degeneracy vs addiction). Some categories (homosexuality, for example) have traversed multiple categories; from sin / moral-criminal act, to medical diagnosis, to natural variation and social acceptance. Elsewhere we might wonder if pedophilia is an illness or a natural variation; certainly, acting on such impulses are rightly criminalized, but how to approach the category and those who inhabit it. Similarly, consider psycho- or socio- paths, or those who display relevant traits, especially as children. Our understanding of the ‘mental illness’ and the various conditions classed as such arguably remains in flux.
legal definition of mental illness
Mental illness: a condition that seriously impairs (either temporarily or permanently) the mental functioning of a person in 1 or more areas of thought, mood, volition, perception, orientation or memory, & is characterised:
(a) by the presence of at least 1 of the following symptoms:
i. delusions;
ii. hallucinations;
iii. serious disorders of streams of thought;
iv. serious disorder of thought form;
v. a severe disturbance of mood; or
(b) by sustained or repeated irrational behaviour that may be taken to indicate the presence of at least 1 of the symptoms mentioned in paragraph (a).
Mental Health Act 2015 (ACT)
NSW and NT adopt similar definitions.
Queensland: a condition characterised by significant disturbance of thought, mood, perception or memory.
SA, TAS, VIC, WA also similar.
THINGS THAT ARE NOT LEGALLY CONSIDERED TO BE MENTAL ILLNESS
Intellectual disability
Substance dependence (addition)
Sexual orientation
Anti-social personality
Religious and spiritual beliefs.
Vaccine denialism!
All may, of course, overlap with a mental illness or, to put it another way, a mental illness may shape or influence the above.
Patient appealed against a community treatment order on the grounds that his belief in historical alien intervention was religious. Alongside other evidence of mental illness, this claim was rejected by the court.
Church of the New Faith v. Commissioner for Pay-Roll Tax (Vic. 1983.)
voluntary inpateints
The majority of patients admitted to mental health units are there voluntarily – thus they have the same rights and freedoms as patients admitted to any other ward. Such patients can leave and, insofar as they have the capacity to do so, they have the right to give their informed consent to treatment. A detention and treatment order may be applied for in relation to a voluntary patient and, if warranted by the circumstance, voluntary patients can become involuntary patients. In NT there is an obligation on psychiatrist to discharge voluntary patients who cannot benefit from their admission, or if leaving the unit is in their best interests.
involuntary patients
Some patients are admitted to mental health units involuntarily. At least initially, this will usually be time limited, possibly for 24-48 hour period of observation. Mental Health Tribunals are required to review decisions to detain and / or compulsorily treat. However, the timetable for reviews varies - 7/10/28 days to 3-months (NSW). Involuntary admission requires strong justification, generally a mentally ill patient must be likely to do ‘serious harm’ to themselves or others whilst mentally disordered persons—individuals who do not have a diagnosis but who are behaving irrationally—must be at risk of ‘serious physical harm.’ This raises a question about what constitutes harm; does financial or reputational harm justify the admission of someone with bipolar disorder who is likely to act against their own interests by, say, gambling or espousing florid conspiracy theories on social media?
law on seclusion and restraints
In some cases, it may be necessary to isolate or restrain patients who are violent and present a risk to staff, other patients and/ or themselves. Restraints can be chemical or physical, the law tends not to explicitly address the former. Both seclusion and restraints are likely to have a negative therapeutic impact. A short-term need may have medium- and long-term consequences. Minimalist Regs: “Any restriction… and any interference with their rights, dignity and self-respect is to be kept to the minimum necessary in the circumstances” (MHA NSW 2007) “a last resort for safety reasons… not punishment” (MHA SA 2009). ACT Chief Psychiatrist; NT sets out criteria for justification and rules for observation etc; VIC more clearly defined seclusion and restraint.
apprehension
If a police officer believes an individual to be mentally ill, they may apprehend them and convey them to a mental health facility if:
* They have reasonable grounds to believe the individual is committing or has recently committed a crime; or
* They believe the individual has recently attempted or probably will attempt to kill themselves or another person, or to cause harm to another person.
The officer must also believe that being taken to the mental health facility will be beneficial to the welfare of the individual concerned. Evidence suggests that officers commonly act beyond this limited scope, and routinely bring individuals to ER depts.
official visitors and auditing
Mental health institutions are subject to external oversight by gvt. appointees who may visit at any time. An official visitor— (a) shall visit and inspect mental health facilities; and (b) shall inquire into: (i) the adequacy of services for the assessment and treatment of [patients] (ii) the appropriateness and standard of facilities for
the recreation, occupation, education, training and rehabilitation of persons receiving treatment… (iii) the extent to which [patients] are being provided the best possible treatment or care appropriate to their needs in the least possible restrictive environment and least possible intrusive manner consistent with… treatment or care; and (iv) any contravention of this Act; and (v) any other matter that an official visitor considers appropriate …; and (vi) any complaint made … by a [patient];
ACT Mental Health (Treatment & Care) Act 1994 [edited]
community treatment orders
Often applied when involuntary patients are discharged from an institution, technically rendering them involuntary outpatients, although there is a presumption that the patient is probably inclined to comply with the order, at least to a degree. One should recall that compelling treatment should require a strong justification. Indeed, in the context of public health, it is higher than the justification required for confinement/ quarantine. In 2016/17 there were 3,423 individuals in VIC with such orders. This is a significant number. One the one hand it is good that patients can retain their liberty. On the other coercing treatment may be counter-therapeutic and damaging to psychiatry’s reputation. Nevertheless, patients often make positive reports, albeit retrospectively. We are surrounded by the therapeutic goods of the mental health and ‘self-help’ industries. Similar concerns motivate aspects of child dev. & education more generally.
mental health and lay understanding/soccial incorporation
This can be formal, as in the case of diagnosing various kinds of learning difficulties, some of which we seek to simply accommodate or account for (dyslexia) others of which we medicate (ADHD). It can be informal, the idea someone or perhaps their child is ‘on the spectrum’ or where individuals lay claim to (un/diagnosed) neurodiversity as an identity. It can be also be seen in the (ab)use of nootropics (cognitive enhancing drugs), something that has been presented as being fairly widespread amongst university students. We may also be in the early days of a more widespread use of psychedelics as a tool for well being. We increasingly perceive ourselves though a ‘neurological’ lens & respond to ‘normal variation’ or a mismatch between self and certain socio-cultural demands via the use of neurochemicals.
the future
As suggested, some are presently attempting neurochemical forms of cognitive enhancement. Others argue that we ought to pursue some kind of moral enhancement in the interest of surviving various existential challenges as a species. Still others suggest that we might make use of ‘love drugs’ to enhance ourselves and our intimate or romantic relationships. In the near future, our therapeutic culture may well incline us to go beyond the restoration of health or the treatment of illness and disease and embrace the ideal of making us ‘better than well.’ Or, for that matter, more than human. Various philosophers, futurists and others think that we will become trans- or post- human. That at at least some of us will become something other that what we are. Ultimately, medicine will be instrumental in that transformation.
